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CMS PEPPER Report

The annual PEPPER report for SNF’s will be released on or about 4/5/19.  To access your facility’s PEPPER data, you need to log on to the TMF website below. Select the appropriate portal based on your CMS Provider Number.

Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) recently released a full listing of 2567 Statement of Deficiencies information compiled through November 2018. This provides a full year of data from state surveys conducted under the revised survey process that is based on the regulations that became effective November 28, 2017. It is noteworthy that three of the top ten most cited deficiencies are #5 – F755 Pharmacy Services, #6 – F761 Labeling and Storage of Drugs and Biologicals, and #10 – F758 Psychotropic Medications. The #1 most cited F-Tag is F880 – Infection Control, which can have significant connection to medication administration practices.

PADONA recommends continuing the close relationship that you have with your pharmacy services provider and consultant pharmacist. Communicate this CMS information and work together to be proactive in preventing these deficiencies in your facility.

Nursing Care Facility Recertification Survey Forms

Attached are forms that are required to be completed and given to the State Agency during recertification surveys. They are being posted in a format that can be saved and provided to the survey team upon entrance.

Please note the Entrance Conference Worksheet for NHA is being provided in addition to a State Entrance Conference Checklist and a SNF Beneficiary Protection Notification form.

Please note the Matrix with Instructions.pdf (CMS-802 (11/2018)) must be used instead of earlier versions.


MDS Teleconference CD Request Form

On January 10, 2019, a training teleconference titled “Updates for a Rapidly Changing MDS World” was presented. To receive a compact disc (CD) of this teleconference, please complete and fax the attached form to Myers and Stauffer at 717-541-1206. The associated handouts will be included on the CD.


MDS coding of item S9085C

Please note that AmeriHealth Caritas (Southwest) and Keystone First (Southeast) are the same CHC plan with differing names.

Both should be coded a “01” at S9085C on the MDS.

Contact List for Directed In-Service Providers

Attached is the contact information for persons who have communicated an interest to provide directed in-service training.

When the remedy of Directed In-Service training is imposed, the facility will be responsible for the procurement of services from an appropriate resource, and the facility will submit a copy of the proposed training program to the supervisor at the State Survey Agency for approval within the same 10-day period that is required for submitting the plan of correction.


Nurse Aide Registry Annotation List

Attached, for your information, is a listing of all nurse aides who have had substantiated findings of resident abuse, neglect or misappropriation of resident property entered on the Pennsylvania Nurse Aide Registry as of January 4, 2019. The Nurse Aides names that have been added since the last issue are bolded.

Verification of a nurse aide’s status must still be done before hiring to verify eligibility for employment in a nursing care facility. An individual nurse aide’s status may be verified by accessing the twenty-four hour online access to the registry via the Department of Health website at www.health.pa.gov/ . Once this site is accessed, click on “Healthcare Facilities” at top of page and next select “Registries” and “Nurse Aides”. Next click on “Nurse Aide Registry On-line”. Choose “Pennsylvania Department of Health” under the program once on the Pearson Vue Pulse portal page and use “Registry Search”.

If you would like additional information or have any questions, please feel free to contact Division of Nursing Care Facility staff at 717-787-1816.


RAI Spotlight Newsletter

Attached is the latest issue of the RAI Spotlight newsletter. Included are details about the next scheduled MDS teleconference.

The RAI Spotlight newsletter is published at the end of February, May, August and November. The four most recent issues are posted in the Bulletins section of the Nursing Facility Report Portal (NFRP). If you are interested in an older issue, please contact the Myers and Stauffer help desk at 717-541-5809. A generic form to request a CD of any teleconference may be found in the Resources section of the NFRP.

Nov.18RAISpotlight Volume 13 Issue 2.pdf

SNF Quality Reporting Provider Preview Reports Are Now Available

Skilled Nursing Facility Provider Preview Reports have been updated and are now available. Providers have until Nov. 30, 2018 to review their performance data on quality measures based on Quarter 2 -2017 to Quarter 1 – 2018 data, prior to the Jan. 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate.

More information can be accessed:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Public-Reporting.html

Skilled Nursing Facility Quality Reporting Program

Fact Sheet on Transitions for New Quality Measures and Data Elements Effective October 1, 2018

FACT Sheet:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-September-2018-Fact-Sheet-on-Transitions-for-New-QMs_508C.pdf

Website Link:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-FAQs-.html

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